The nurse will be using the Braden Scale with each admit to the longterm care center. Which of these will be utilized in a Braden Scale assessment? (Select all that apply.)

Choice A reason: A decreased level of rheumatoid factor is not seen in clients with rheumatoid arthritis. Rheumatoid factor is an antibody that is produced by the immune system and can bind to other antibodies. A high level of rheumatoid factor indicates an autoimmune disorder, such as rheumatoid arthritis.

Choice B reason: A negative rheumatoid factor is not seen in clients with rheumatoid arthritis. A negative rheumatoid factor means that the antibody is not detected in the blood. A negative rheumatoid factor does not rule out rheumatoid arthritis, but it may suggest a different type of arthritis or another condition.

Choice C reason: A positive rheumatoid factor is seen in clients with rheumatoid arthritis. A positive rheumatoid factor means that the antibody is detected in the blood. A positive rheumatoid factor is more likely to occur in clients with rheumatoid arthritis, especially during a flareup of the disease.

Choice D reason: Factor does not change is not seen in clients with rheumatoid arthritis. Rheumatoid factor can vary over time and may change depending on the activity of the disease. Rheumatoid factor may increase during a flareup and decrease during remission.

Choice A reason: This is the best intervention because it helps the nurse to understand the client's emotional, social, and practical needs and resources. A new diagnosis of HIV can be a devastating and overwhelming experience for the client, who may face stigma, discrimination, isolation, or rejection from others. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide comfort, guidance, and assistance to the client. The nurse should also encourage the client to seek professional counseling, peer support, or other services as needed.

Choice B reason: This is not the best intervention because it may not respect the client's preferences, beliefs, or values. The nurse should not assume that the client wants or needs spiritual or religious support, unless the client expresses such a desire. The nurse should ask the client about their spiritual or religious beliefs and practices and provide appropriate referrals or resources as requested by the client. The nurse should also respect the client's right to privacy and confidentiality and not disclose the client's diagnosis to anyone without the client's consent.

Choice C reason: This is not the best intervention because it may not be the most urgent or appropriate topic to discuss with the client at this time. The nurse should not focus on the legal or ethical aspects of the client's diagnosis, but rather on the client's emotional and physical wellbeing. The nurse should explain the legal requirement to tell sex partners in a sensitive and respectful manner, but only after the client has accepted and understood their diagnosis and has expressed readiness to disclose their status to others. The nurse should also provide the client with information and resources on how to prevent the transmission of HIV and how to protect themselves and their partners.

Choice D reason: This is not the best intervention because it may not be the client's wish or choice. The nurse should not offer to tell the family for the client, unless the client asks for such help. The nurse should respect the client's autonomy and decisionmaking regarding whom to tell and when to tell about their diagnosis. The nurse should also support the client in preparing for the possible reactions and outcomes of disclosing their status to their family and others.